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This Royal College of Psychiatrists position statement examines how menopause affects mental health and its implications for clinical practice, services, and policy across the UK. Drawing on lived experience, clinical evidence and an intersectional approach, it highlights that menopause can significantly impact mental health and wellbeing, and is associated with anxiety, depression, cognitive changes and, sometimes, triggering or worsening serious mental illness. These effects are not experienced equally: people with severe mental illness, neurodivergence, minority ethnic backgrounds, LGBTQ+ identities, disabilities, or trauma histories often face greater barriers to care and poorer outcomes. Workplace impacts are also considerable, and gaps in clinical understanding, diagnostic overshadowing, limited access to HRT, and insufficient training across the mental health workforce further hinder effective support. This statement calls for: Greater awareness of menopause’s links to mental health Better training for psychiatrists and the wider workforce Fair access to diagnosis, treatment (including HRT) and mental health support The relationship between menopause and mental health to be fully integrated into the development and implementation of national women's health strategies Stronger, more supportive workplace policies Increased research across the board, and especially for under-represented groups Without proper support, many women struggle unnecessarily during the time of menopause transition. This statement outlines how healthcare, policy and workplaces can better respond to ensure compassionate, equitable and evidence-based care.

This investigation by the Healthcare Safety Investigation Branch (HSIB) aimed to support improvements in the work of community mental health teams (CMHTs). Specifically, the investigation looked at the following four areas: assessing a patient’s risk of self-harm or suicide considering menopause as a risk factor for mental health conditions engaging with families caring for people with a first episode of psychosis. Reference event Ms A was 56 years old when she came into contact with mental health services for the first time in September 2019, following a suicide attempt. Ms A spent a month in hospital, and was then discharged home under the care of a community mental health team (CMHT) with a diagnosis of psychotic depression. At the end of May 2020, Ms A was again admitted to hospital following a second suicide attempt. She again stayed in the hospital for about four weeks before being discharged home under the care of a CMHT. Ms A was seen by CMHT workers regularly throughout July, and had a telephone review with a consultant psychiatrist. At the end of July, Ms A’s family became increasingly concerned about her mental state and were unable to make contact with her. On 2 August, Ms A was found deceased at home having died by suicide. Findings While national guidance says that a patient’s risk of harm should not be stratified into categories such as high, medium or low, such stratification remains common in many trusts. This is because other methods of assessing and documenting risk are not available, and because staff fear being blamed if a patient comes to harm without a risk assessment, including risk stratification, having been completed. Current research only demonstrates a link between menopause and low mood, and not between menopause and more severe mental health symptoms. Women are frequently prescribed antidepressant medication when hormone replacement therapy may be a more appropriate treatment for their symptoms. Menopause is not routinely considered as a contributing factor in women with low mood who are assessed by mental health services, and staff do not receive training in this area as standard. While there is a significant amount of national guidance relating to family engagement when treating patients with mental health conditions, mental health practitioners often find it difficult to know how and when to engage with families with complicated relationships or when the patient withdraws their consent for information sharing. There is a lack of training in this area to support staff with decision making. National guidance raised the upper age limit for referral to the Early Intervention in Psychosis pathway in 2016. Some trusts continue to prioritise younger patients for a variety of reasons – including funding, capacity and misconceptions about whether an older person can actually be experiencing a true first episode of psychosis in later life. Safety recommendations HSIB has made four safety recommendations as a result of this investigation. NHS England: HSIB recommends that NHS England works with appropriate stakeholders, including experts with appropriate experience, to create guidance on culture change. A quality improvement programme should also be developed to support practitioners in undertaking psychosocial assessments that are in line with guidance from the National Institute for Health and Care Excellence. Person-centred safety planning should be embedded within the process. Care Quality Commission (CQC): HSIB recommends that the Care Quality Commission evaluates the way in which it reviews how community mental health services assess risk of harm, to ensure its inspections are in line with the latest national guidance. National Institute for Health and Care Excellence (NICE): HSIB recommends that the National Institute for Health and Care Excellence evaluates the available research relating to the risks associated with menopause on mental health and if appropriate, updates existing guidance. Royal College of Psychiatrists (RCPsych): HSIB recommends that the Royal College of Psychiatrists forms a working group with relevant stakeholders to identify ways in which menopause can be considered during mental health assessments. Safety observations HSIB has made the following safety observations: It may be beneficial for mental health organisations to have a dedicated liaison officer who acts as a point of contact for both families and clinicians when navigating involvement in a patient’s care and decision making. It may be beneficial for organisations to involve families in care planning and assessments, and that practitioners are appropriately trained in working with families. It may be beneficial for education bodies to develop training programmes in safety planning and psychosocial assessments, once NHS England has provided guidance on how such assessments should be conducted. It may be beneficial for mental health organisations to ensure their Early Intervention in Psychosis referral process is in line with the national guidance, and that staff are clear about the upper age limit of patients accepted onto the pathway. Safety actions HSIB has noted the following safety action: NHS England has written to all mental health trusts in England to highlight the importance of taking a person-centred approach to psychosocial assessments and safety planning. The communication asks trusts to move away from risk assessment tools that stratify an individual’s risk of suicide or self-harm.

Many healthcare professionals are not trained in menopause care. The British Menopause Society (BMS) runs a training programme for healthcare professionals in the principles and practices of menopause care. The programme comprises progressive theory and practical training components designed to reflect modern NHS practice and meet the ever-increasing requirement for quality menopause education. The BMS Principles and Practice of Menopause Care course is for healthcare professionals seeking an in-depth and comprehensive grounding in menopause care. This course is suitable for doctors, nurses and pharmacists wishing to understand the essential foundations of menopause care The BMS Certificate in the Principles and Practice of Menopause Care for doctors and nurses who undertake menopause consultations in general practice, including NHS and private clinics. It is also suitable for pharmacists (clinical and independent prescribers). The BMS Advanced Certificate in the Principles and Practice of Menopause Care for doctors, independent nurse prescribers and pharmacist independent prescribers who wish to provide specialist menopause care, including management of complex cases. View the competency-based PPMC curriculum Apply now for a BMS PPMC course Apply now for the competency-based practical training

HSJ hosts the Patient Safety Watch newsletter, written by Patient Safety Watch chief executive James Titcombe.

Jacqueline Anne Potter, known as Anne, was a 54 year old teacher who died by suicide following a decline in her mental health. Anne died during overnight leave from an acute psychiatric unit in Somerset, where she was being looked after because of mental health issues exacerbated by menopause. In this report, the coroner raises concerns about her care and the lack of importance given to menopausal care in the NHS. Coroner's matters of concern Overnight leave arrangements When Anne was sent on her first overnight leave there was no codified ‘risk’ and ‘safety planning’ document. While in Anne’s case the report notes that it was widely accepted that her husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, the Coroner noted that this may not apply in other cases. The report said that whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained. The Coroner suggests that this could help equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones while they are in the community. Internet access in mental health settings The report notes that it found that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide. The Coroner noted that workplace organisations do have the ability to block sites if they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content, etc). The report states that by allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths. Menopausal care The Coroner noted several areas of concern about menopausal care available on the NHS: Menopausal training is not mandatory in any area of clinical practice or specialism. The Coroner expressed concerns that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as mental health practice, obstetrics and gynaecology, and oncology, or even general as a general GP. The Coroner noted that she was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations. Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist. She also noted that: “I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms. If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.” Concluding, the Coroner referenced being told in a response to a previous Prevention of Future Deaths report where she raised similar concerns about a roll-out of specialist menopausal care and upskilling of GPs. She stated that from reviewing this case there was little evidence that this has happened/is happening and said that women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing.

The second annual Safety For All conference was held at the Royal College of Physicians in London on Tuesday 5th December 2023. Over 100 members of the healthcare community attended this event, including occupational health professionals, patient safety experts, frontline staff, patients and academics. The conference was hosted by the Safer Healthcare and Biosafety Network and Patient Safety Learning as part of the Safety For All campaign, supported by B. Braun, BD, Boston Scientific and Stryker. Attendees had the opportunity to hear from two keynote speakers: Lynn Woolsey, UK Deputy Chief Nurse at the Royal College of Nursing and Dr Henrietta Hughes, Patient Safety Commissioner for England. The conference was chaired and facilitated by Dr Rob Galloway, A&E Consultant at Brighton and Sussex Hospital NHS Trust, with a welcome introduction from Dr Ian Bullock, CEO of the Royal College of Physicians. There were a number of panel sessions and presentations throughout the day which are summarised in the attachment below, including on sustainability, antimicrobial resistance and antibiotic underdosing, violence at work, clinical communications, human factors, implementing the Patient Safety Incident Response Framework (PSIRF), and women's health and the menopause.